Good Samaritan Hospital Emergency Department Expansion

GENERAL

Company Name *

Certificate upload *

Maximum file size: 134.22MB

Upload a copy of your certificate(s) and/or screenshot(s) verifying the above reported status. * If you do not have any verifications, please be sure to check the box above for None or Not Applicable*

PRIMARY (CORPORATE) OFFICE INFORMATION

Address

City

State

Zip

Phone No.

Fax No.

Formation Date *

(Use this format: mm-dd-yyyy)

State of Formation *

DBA or Trade Name

Website

Tax ID (EIN) *

Dun & Bradstreet #

NAICS Code

PRIMARY CONTACT

Primary's Name *

Primary's Title *

Email *

Phone Number *

SECONDARY CONTACT

Secondary's Name

Secondary's Title

Phone Number

CLAIMS CONTACT

Claim Contact Name

Claim Contact Title

Phone Number

OFFICERS

Name

Title

Add Remove

STOCKHOLDERS

(include only those owning 5% of more of stock. Attach a supplemental sheet if needed.)

Name

% Stock Ownership

Add Remove

COLLECTIVE BARGAINING AGREEMENTS

(Identify union affiliations)

Name

Add Remove

Do you have experience with projects that require Certified Payroll and Davis Bacon Wage Rate?

Yes

SERVICE CAPABILITIES

State *

License Number

Add Remove

SERVICES PROVIDED

(Select all services that apply)

Service Provided - Checkboxes *

Upload your statement of qualifications:

Maximum file size: 5MB

STAFFING

Professional (Licensed)

Technical (Non-professional)

Administrative

Total Staffing

OFFICE LOCATIONS & REGIONS SERVED

(Including primary office)

Location *

Staff *

Services Provided *

Lookup

Add Remove

[Select Your Country]

[Select your state] *

LITIGATION / CONTRACT DISPUTES

List any judments, arbitrations, liens, insurance claims, or lawsuits the firm has been subject to within the past 5 years. If there are none, respond by saying there were none.

Please enter all judgements, arbitrations, liens, insurance claims, and/or lawsuit descriptions: *

Has firm at any time failed to complete a contract or had a contract terminated? *

Yes

If yes, please explain: *

File Upload

Maximum file size: 5MB

CRIMINAL BACKGROUND INFORMATION

Has the firm, any affiliate, or any of the current or former principal owners, stockholders, or officers or managerial employees:

been convicted of a misdemeanor and/or found in violation of any administrative, statutory, or regulatory provisions in the past five (5) years? *

Yes

been convicted of a felony, and/or crime related to truthfulness and/or business conduct in the past ten (10) years? *

Yes

have any felony, misdemeanor and/or administrative charges currently pending? *

Yes

If you answered "Yes" to any of the above questions, please provide an explanation:

Insurance Coverage

State your standard coverage limits in COLUMN 2 below.

POLICY

Occurrence (or claim) limit

Aggregate limit

GCL

GCL Occurrence Limit

GCL Aggregate Limit

Auto

Auto Occurrence Limit

Auto Aggregate Limit

Umbrella / Excess

Umbrella / Excess Occurrence Limit

Umbrella / Excess Aggregate Limit

Pollution / Liability

Pollution Liability Occurrence Limit

Pollution Liability Aggregate Limit

Workers Compensation

Workers Compensation Occurrence Limit

Workers Compensation Aggregate Limit

Professional Liability

Professional Liability Occurrence Limit

Professional Liability Aggregate Limit

Cyber / Network Security Liability

Cyber / Network Liability Occurrence Limit

Cyber / Network Liability Aggregate Limit

If a contract requires additional insurance limits, would you be willing to consider purchasing additional insurance coverage? *

Yes

Health & Safety

Do you have a written Health & Safety Program? *

Yes

If Yes, please attach a copy. *

Maximum file size: 134.22MB

Do you provide site-specific Health & Safety Plans? *

Yes

Who is responsible for executing the site specific plans?

Does your site-specific health and safety plans include Job Hazard Analysis (JHA)? *

Yes

If Yes, provide an example for similar services to be provided.

Whats is the number of safety professionals on-staff within your firm? *

Does your Health & Safety Program call for field safety inspections?

Yes

If Yes, who conducts them and how often?

If Yes, do you document findings of inspections and provide written reports on outcomes?

Yes

Do you have an Accident Investigation & Reporting Program? *

Yes

Do you have a drug and alcohol screening program? *

Yes

Do you currently conduct pre-employment drug and alcohol screening? *

Yes

If No, are you willing to conduct drug and alcohol screening if so directed by a contract?

Yes

Are employees provided with health and safety training? *

Yes

Health & Safety (Cont.)

If Yes, does the training include:

Company Health and Training Policy

Yes

Company Health and Safety Rules and Safe Work Practices

Yes

Driving Safety

Yes

Electrical Safety

Yes

Fall Protection

Yes

Hazard Recognition and Reporting

Yes

Injury Reporting

Yes

Personal Protective Equipment

Yes

Fire Prevention

Yes

Housekeeping

Yes

Emergency Response and Rescue

Yes

First Aid

Yes

Safety Meeting Attendance

Yes

Radio Frequency Energy Safety Training Program

Yes

Competent Tower Climber and Rescue Training

Yes

Confined Space Training

Yes

Energy Isolation and Lockout / Tagout

Yes

Hazard Communication Training

Yes

Motorized Equipment Operator Training

Yes

Excavation and Trenching

Yes

Health & Safety (Cont.)

How many of your employees had OSHA 10-Hour training in the past 3 years?

How many of your employees had OSHA 30-Hour training in the past 3 years?

Does the work your employees perform require the use of fall-arrest equipment? *

Yes

Do you retain the services of an outside safety consultant? *

Yes

Do you conduct safety meetings? *

Yes

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Do you conduct Toolbox Talks? *

Yes

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Do you employ full-time competent tower climbers and rescue personnel? *

Yes

If Yes, how often? (e.g. daily, weekly, monthly) Explain.

Health & Safety (Cont.)

Provide the following information for the last 3 years. You must respond to all questions even if your firm is not required to maintain OSHA logs.

YEAR (most recent 3 years)

Current Year

Prior Year

Worker's Compensation
Experience Modification Rate (EMR)

Worker's Compensation Experience Modification Rate (EMR) (Current Year) *

Worker's Compensation Experience Modification Rate (EMR) (Prior Year)

Number of Fatalities
(list any, explain in Supplemental Information field at the end of this form.)

Number of Fatalities (Current Year)

Number of Fatalities (Prior Year)

Lost Work Day Incident Rate
(total lost-time recordable cases x 200,000 / total hours worked.)

Lost Work Day Incident Rate (Current Year) *

Lost Work Day Incident Rate (Prior Year) *

OSHA Recordable Incident Rate
(total OSHA recordable cases x 200,000 / total hours worked)

OSHA Recordable Incident Rate (Current Year)

OSHA Recordable Incident Rate (Prior Year)

Total Number of Hours Worked
(per occurrence)

Total Number of Hours Worked (Current Year)

Total Number of Hours Worked (Prior Year)

The following upload fields allow for uploading of multiple files.

To upload multiple files please click-and-hold the CTRL key and left-click with your mouse.
Once you have selected the file(s) hit the "Open" button on the the dialog box.

Attach copies of your OSHA 300 & 300A logs for the last 3 years (Not required).

Maximum file size: 10MB

Attach documentation from your insurance broker supporting EMRs. *

Maximum file size: 10MB

Attach a copy of your WC Loss Run if you were not issued an EMR. If current EMR is greater than 1.0,
provide explanation of actions being taken to reduce this rate in the "Supplemental Information" box at the end of this form (Not required).

Maximum file size: 10MB

Quality Assurance (QA) / Quality Control (QC) Practices

List the primary QA practices you normally perform to ensure delivery of a quality product.

Do you have a QA program? *

Yes

Do you perform quality control? *

Yes

Is the QA program based on ISO 9000? *

Yes

Do you formally train management and technical staff on quality improvement techniques? *

Yes

If yes, describe your quality control:

If not based on ISO 9000, provide name of standard used:

Do you perform quality assurance audits? *

Yes

If yes, describe your quality assurance audits:

PERFORMANCE

Similar Contracts - List 3 contracts (within the last 5 years) for which your firm is providing services similar to those your firm is seeking to be prequalified for.

Contract Name & Scope

Location

Client Type

Public

Private (Owner)

Private (Other)

Fee

Less than $10,000

$10,000 to $100,000

More than $100,000

Period of Performance

Add Remove

PRIOR CONTRACT WITH TECTONIC

If you have previously performed services for Tectonic, list up to 3 projects and the scope of work performed.

Project Name

Scope of Work

Add Remove

PROJECT PERFORMANCE REFERENCES

List a minimum of 3 references for services performed within the last 3 years. REFERENCES MUST BE KNOWLEDGEABLE OF AND ABLE TO COMMENT ON YOUR FIRM’S ADHERENCE TO PROJECT BUDGETS AND SCHEDULES.

Client

Service Provided

Representative

Telephone Number

Email Address

Add Remove

PERFORMANCE ISSUES

Has firm at any time failed to complete a contract or had a contract terminated?

Yes

If yes, please explain: (provide supplemental information sheet if needed)

LITIGATION / CONTRACT DISPUTES has the firm been subject to any of the following within the past 5 years?

Judgements

Yes

Liens

Yes

Insurance Claims

Yes

Lawsuits

Yes

If Yes to any of the above, have any rulings, outcomes, or judgements been made against the firm as a result?

Yes

(If "Yes", provide more information for each on a supplemental sheet.)

SUPPLEMENTAL INFORMATION

SUPPLEMENTAL INFORMATION *

Supplemental Uploads

Required upload size: 10MB - 134.22MB

CERTIFICATION

The undersigned certifies, under penalty of law, that the information provided and the representations are accurate and current. Making false representations or providing inaccurate information may result with being disqualified as a prequalified consultant or in termination of a contract.

NAME *

TITLE *

DATE

Please note: When you save the information as draft your attachments will also be saved.

FOR TECTONIC USE ONLY

Vendor Qualified:

Yes

Approved by:

Date:

Vendor ID Number:

Section

1) Project Name and Location *

Section

6) In what areas do you think the inspector(s) can improve? *

Section

11) What do you think we can do to make our inspections better? *

12) What in our forms should be changed to make them clearer and more informative? *

13) What do you think we can do to make our "Equipment Calibration Program" better? *

14) Could we contact you about this feedback? *

Yes

14a) Please provide us with your contact *

(Please fill only if you answered "Yes" in the previous question)

Please verify your input by checking the box below.

Section

Contact Name: *

Your name

Company Name: *

The company you're working with

Phone Number: *

A contact phone number if you would like to be contacted (In this format XXX-XXX-XXXX)

Did you receive your report(s) in a timely manner? *

Yes

Were you pleased with the customer service you received? *

Yes

Did you have sufficient information? *

Yes

Did you receive your final report in a timely manner? *

Yes

Please let us know how we can improve our service. *

Feel free to express your views of TECTONIC service.

Please verify your input by checking the box below.

Select a Prequalification form...

Become a prequalified vendor

INSTRUCTIONS

GENERAL

PRIMARY (CORPORATE) OFFICE INFORMATION

PRIMARY CONTACT

SECONDARY CONTACT

CLAIMS CONTACT

OFFICERS

STOCKHOLDERS

COLLECTIVE BARGAINING AGREEMENTS

SERVICE CAPABILITIES

SERVICES PROVIDED

STAFFING

OFFICE LOCATIONS & REGIONS SERVED

LITIGATION / CONTRACT DISPUTES

CRIMINAL BACKGROUND INFORMATION

Insurance Coverage

Health & Safety

Health & Safety (Cont.)

Health & Safety (Cont.)

Health & Safety (Cont.)

The following upload fields allow for uploading of multiple files.

Quality Assurance (QA) / Quality Control (QC) Practices

PERFORMANCE

PRIOR CONTRACT WITH TECTONIC

PROJECT PERFORMANCE REFERENCES

PERFORMANCE ISSUES

LITIGATION / CONTRACT DISPUTES has the firm been subject to any of the following within the past 5 years?

SUPPLEMENTAL INFORMATION

CERTIFICATION

FOR TECTONIC USE ONLY

Special Inspection Feedback Form

Section

Section

Section

Service Evaluation

Section

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